The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � ��.., . � TOWN OF YARMOUTH BOARD OF HEALTH �` y �"'� � � APPLICATION FOR LICENSE/PERM T -2017 ��E,, NOV 2 S �O�6 �"°" * Please complete form and attach all necess „s��ce �ier 16 2016. Failure to do so will result in the retu�o , a`..,lic�ic��; : ke1HFA�TF-I DEPT. � Y �:.t p�? ,. ._ _R, ESTABLISHMENT NAME: �5 e ��,.s� ��.•�t G ' a�.� �i A ia.3 TAX ID: �o ��9fs'9� LOCATIONADDRESS: a �i�� s r --��`� �. o TEL.#: ��'�9� -��e� MAILING ADDRESS: �SPi�E ��-�- /� v� .e�c`-�u/�c� / DaZ � E-MAIL ADDRESS: /�.ur,e @,�v,6W�q�,�u�o��c�roc�P .�o� OWNER NAME: CORPORATION NAME (IF APPLICABLE): �� c v •—v� L � ' MANAGER'S NAME: %,e� Sy�P,7��9 TEL.#:�ok 39� -�Saz� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. _----_ _._ --- - _ ?- t __ __ _ __ __------_ _ . �. _ _ _ Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. / ' ,' �,,� 1. �U�I �y!-�✓f�Lfl 2. �GNNiG��PV�iSE PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. lo� � ��,��z�4 2. -✓��c-.� �1/,�c r�LLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your establishment. �' / 1. �D� / �`�'�9'/1 Z A� 2. -✓�iviv�i�i�' �S� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 2. 3. 4• RESTAURANT SEATING: TOTAL# .-� ' OFFICE USE ONLY I LODGING: ---— - ', LII;ENS�RF,QUII2F.D FEE PEf2MIT# LICENSE REQUIRED FEE YERMIT# LICENSE REQUjRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $l lt�ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �-z7 —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.8. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ IZS-OO **x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 40��c�yt4.0-Z f i ADMINISTRATION F Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED ✓ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be '; limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. �RVIC�___---_--___ __:___�.__�__ __�__----- -- SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. ' CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16, 2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. /� DATE: SIGNATURE: � PRINT NAME& TITLE: J,J �S /��t/�/ ��=�I,c3€r2- Rev. 10/12/16 ' ' ` � T'he Commonwealth of Massachusetts Department of Industrial Accidents , Office of Investigations � I Congress Street, Suite I00 � Baston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Geaeral Businesses Applicant Iaformation Please Print Legiblv Business/Organization Name: �v,e ��c,�vrs�77v�/� �L� �� 3�� Address: %� {'�rfi�� T/fT�' �� City/State/Zip:s. ,�� ' Phone #: Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with /D employees(full and/ 5. �Retail or part-time).* 6. ❑ Resta.urantlBar/Eating Establishment _2.[�-I s�:s .,,Y .' � a��r�:r�.'�c,�_ — _�._U Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an arganization shouid check box#L I am an employer that is providing workers'co�npensation insurance for my employees Below is the policy information. Insurance Company Name: (�,v�Ti�✓EN�c- �.�5(�i4�`� �/�1��'✓� � Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # �d/�.3 7 1'�� Expiration Date: f��5��/� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine�a��o g},�9��.�,��-y�a�irr.�-i��r.:n��t,ws�e��as ei�il�nalties in t1:e fUr.m of��TOP�JJ4P.K��tL��:��a�ne of up to$250.00 a day against the violator. Be advise3 that a�opy of this stat�ment m$y be forwarded to the Qffice cf Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. �� Si ature: � � Date: � �7 ��° Phone#: �/��'�%�� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia ! .�►c'R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM10DfYYYY) 10/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVE�Y AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIPICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in ifeu of such endorsement(s�. PRODUCER CONTACT CS&S/BROWN&BROWN OF CT,INC. NAME: PO BOX 94BSSO . PHONE . . ... FAX � � �(A/C,No,Exq: (A/C,No): MAITLAND,FL 32794-6580 E-MAIL Phone-866-883-7159 ADDRESS: F8X-H77-7G3-S�ZY INSURER(S)AFFORDING COVERAGE � NAIC# � �r,suReRn:Transportation Insurance Company 2o49a INSURED INSURER 8: SUB ACQUISITION LLC DBA SUBWAY 45 PINE HILL DRIVE iNsuReac: EAST GREENWICH,R102878 INSURERD: �n,suReRe:Continental Casuaity Company 20443 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLiCY PERIOD IND�CATED. NOTWITHST;,NOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICI€S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS QF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDIlCED BY PAID DC/lIMS. . , , .. �: :;, .: . ,r,•._ :. -.., -7�-,.�-'_.-, -. :. a . ;.: . 1 SR ADDL SUBR POLICY EFF OL Y EX �� 7YPE OF INSURANCE INSR WVD POUCY NUMBER MMIDO (MNUDD � �� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE SZ�OOO,OOO CLAIMS-MADE �OCCUR DAMAGE 70 RENTED ' $$OO,OOO PREMISES(Ea oaurrence) A Y N 4012379760 11/25/2016 11/25/2017 MEDEXP(Myoneperson) $10�000 PERSONAI&ADV INJURY S2�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAI AGGREGATE S4�OOO�OOO � POLICY❑�E0. �LOC PRODUCTS-COMP/OP AGG S4rQOO�OOO OTHER AUTOPAOBILE LIABILITY COMBINED SINGLE LIMIT ��OOO�OOO . (Ea accident) � ANY AUTO BODILY INJURY(Par person) A AUTOS NE� AUTOSULED N N 4012379760 11/25/2016 11/25/2017 BODILY INJURY(Per accident) � HIREDAUTOS �JON-0YlTlED - � - � � PROPERTYDAMAGE " AUTOS (Per accitlent) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILI7Y STATUTE ER ANY PROPRIETORlPARTNEWEXECUTIVE y�N E.L.ERCHACCIDENT $�OO�OOO E OFFICERfMEMBER EXCLUDED? N N 4012379788 11/25/2016 11/25l2017 (Mandatory in NH) � E.L.DISEASE-EA EMPLOYEE $�OO,OOO If yes,desuibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT SSOO,OOQ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Atfach AGORD�t01,Adtlition�RemaAcs Schetluie,if mae space b required): - . - . � ' ..� . . .. � � � � Certificate Holder is named as Additional Insured-Managers or Lessors of Premises as provided within the Bianket Additional Insured Endorsement. 2145 lyannough Road,West Barnstable,MA,02668,Store#23787 CERTIFICATE HOLDER CANCELLATION MassDot reystone CO SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEPORE c/o Greystone Management Solutions as designated THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN R@pf2S@tl�tlVC ACCORDANCE WITH THE POUCY PROVISIONS. 20 Park Plaza,Suite 1120 AUTHORIZEDREPRESENTATIVE Boston,MA 02116 ��}.,..�.y7t��y�_n:�,,±:a�cc:�.- � '`J O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD cacasia